What is the best medication for treating diastolic hypertension?

Best Medication for Diastolic Hypertension

ACE inhibitors are the first-line treatment for diastolic hypertension due to their effectiveness in reducing cardiovascular events, mortality, and improving diastolic function. 1

First-Line Medication Options

• ACE inhibitors (like lisinopril) are recommended as first-line agents for diastolic hypertension, particularly beneficial for patients with diabetes, microalbuminuria, or clinical nephropathy 1, 2
• Thiazide-type diuretics (especially chlortalidone) are also appropriate first-line agents, either alone or in combination with other medications, particularly for uncomplicated hypertension 1, 3
• ARBs (like losartan) can be used if ACE inhibitors are not tolerated and have shown effectiveness in reducing cardiovascular events, particularly stroke 4, 1
• Dihydropyridine calcium channel blockers are effective alternatives, especially in elderly patients with isolated systolic hypertension 4, 1

Treatment Algorithm

1. Initial Assessment:

   • For BP 130-139/80-89 mmHg: Start with lifestyle modifications for up to 3 months 4, 5
   • For BP ≥140/90 mmHg: Initiate both lifestyle modifications and pharmacological treatment promptly 4, 5

2. First-Line Pharmacological Treatment:

   • Start with an ACE inhibitor like lisinopril, which has demonstrated effectiveness in reducing diastolic blood pressure and improving diastolic function 1, 2, 6
   • If ACE inhibitor is not tolerated (e.g., due to cough), switch to an ARB 1, 5

3. Combination Therapy:

   • If blood pressure control is inadequate with monotherapy, add a thiazide diuretic or calcium channel blocker 5, 2
   • For most patients with confirmed hypertension (≥140/90 mmHg), consider initiating with combination therapy 5

4. Triple Therapy:

   • If BP remains uncontrolled on dual therapy, use a combination of ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 5

Treatment Targets

• The goal for most adults should be a blood pressure of 120-129 mmHg systolic and <80 mmHg diastolic 4, 1
• For patients with diabetes, chronic renal disease, or established cardiovascular disease, target <130/80 mmHg 4, 5
• If treatment is poorly tolerated, follow the "as low as reasonably achievable" (ALARA) principle 4

Evidence Supporting ACE Inhibitors

• ACE inhibitors like lisinopril have been shown to reduce all-cause mortality in hypertensive patients 3
• They prevent approximately 2-3 deaths and 2 strokes per 100 patients treated for 4-5 years 3
• Lisinopril produces significant reductions in both systolic (11-15%) and diastolic (13-17%) blood pressure when given once daily 7
• ACE inhibitors have been shown to improve measures of diastolic function, making them particularly beneficial for diastolic hypertension 6

Special Considerations

• In elderly patients, treatment should follow the same guidelines as for younger people, provided it is well tolerated 4
• Test for orthostatic hypotension before starting or intensifying BP-lowering medication, especially in elderly patients 4
• Monitor renal function and serum potassium levels when using ACE inhibitors or ARBs 5
• ACE inhibitors are contraindicated during pregnancy; preferred agents during pregnancy include dihydropyridine CCBs, labetalol, and methyldopa 4

Common Pitfalls and Caveats

• Beta-blockers are no longer considered first-line for uncomplicated hypertension unless there are specific indications (e.g., coronary artery disease, heart failure) 4, 5
• Thiazide diuretics can provoke hyperglycemia and diabetes, although this does not reduce their efficacy in preventing cardiovascular events 3
• ACE inhibitors may be less effective in Black patients as monotherapy 2
• Combining ACE inhibitors with ARBs is not recommended due to increased risk of adverse effects without additional benefit 5

Lifestyle Modifications

• Reduction of weight to achieve a healthy BMI (18.5-24.9 kg/m²) 5
• Regular aerobic physical activity: 150 minutes of moderate intensity or 90 minutes of vigorous exercise per week 5
• Sodium restriction: 1200-2300 mg/day 5
• Moderation in alcohol consumption 5
• Diet rich in fruits, vegetables, low-fat dairy products, and reduced in saturated fats 5
• Smoking cessation 5